Factors influencing time from presentation to treatment of colorectal and breast cancer in urban and rural areas

The effect of comorbidities on diagnostic interval for lung cancer in England: a cohort study using electronic health record data

BACKGROUND

Comorbid conditions may delay lung cancer diagnosis by placing demand on general practioners' time reducing the possibility of prompt cancer investigation ("competing demand conditions"), or by offering a plausible non-cancer explanation for signs/symptoms ("alternative explanation conditions").

METHOD

Patients in England born before 1955 and diagnosed with incident lung cancer between 1990 and 2019 were identified in the Clinical Practice Research Datalink and linked hospital admission and cancer registry data. Diagnostic interval was defined as time from first presentation in primary care with a relevant sign/symptom to the diagnosis date. 14 comorbidities were classified as ten "competing demand" and four "alternative explanation" conditions. Associations with diagnostic interval were investigated using multivariable linear regression models.

RESULTS

Complete data were available for 11870 lung cancer patients. In adjusted analyses diagnostic interval was longer for patients with "alternative explanation" conditions, by 31 and 74 days in patients with one and ≥2 conditions respectively versus those with none. Number of "competing demand" conditions did not remain in the final adjusted regression model for diagnostic interval.

CONCLUSIONS

Conditions offering alternative explanations for lung cancer symptoms are associated with increased diagnostic intervals. Clinical guidelines should incorporate the impact of alternative and competing causes upon delayed diagnosis.

Determining factors of presentation and diagnosis delays in patients with colorectal cancer and the impact on stage: a cross sectional study in Yogyakarta, Indonesia

Background

Early colorectal cancer (CRC) symptom recognition and prompt diagnosis are crucial for the identification of cases in the earliest stage and for improving survival. This study investigates the incidence of presentation and diagnosis delays, their contributing determinants and their impact on the cancer stage at diagnosis.

Methods

This cross-sectional study recruited 227 CRC patients between November 2022 and October 2023. We developed a semi-structured questionnaire to collect information on the factors related to delays in the presentation and diagnosis. Presentation delay was defined as the time between the initial symptoms and the first consultation exceeding 1 month, while diagnosis delay was defined as the time between presentation and the pathological diagnosis confirmation exceeding 4 months. We examined the impact of these delays on the status of the metastatic disease and identified the determinants of the presentation and diagnosis delays.

Results

The median values for presentation and diagnosis delay are 1 and 4 months, respectively. Patients aged ≥60 years were less likely to experience diagnosis delays odds ratio (OR = 0.52, 95% confidence interval (CI) 0.28-0.95, p = 0.035), as opposed to those who were younger. The absence of red flag symptoms at presentation (OR = 2.73, 95% CI 1.47-5.10, p = 0.002), the utilisation of complementary and alternative medicine (OR = 2.01, 95% CI 1.12-3.61, p = 0.019) and ≥3 distinct healthcare facility visits before diagnosis (OR = 3.51, 95% CI 1.95-6.29, p < 0.001) were associated with an increased risk of diagnosis delays. Diagnosis delays were also correlated with a higher risk of metastatic disease at diagnosis (OR = 2.04, 95% CI 1.17-3.53, p = 0.011).

Conclusion

Our CRC patients experience considerable delays in their presentation and diagnosis. Diagnosis delays were observed to increase the likelihood of presenting with metastatic disease. Given the determinants and the patients' perspectives revealed in this study, future research to explore evidence-based approaches to reducing these delays is warranted.

Trends in and Prognostic Significance of Time to Treatment in Pancreatic Cancer: A Population-Based Study

INTRODUCTION

The association of time to treatment (TTT) with survival remains unclear in pancreatic adenocarcinoma (PDAC). In this study, we evaluate the recent trends in TTT, causes for delay, and its effect on survival.

METHODS

We included patients with PDAC of all stages from the National Cancer Database (2004-2020) who underwent either surgery or chemotherapy/radiotherapy (CT/RT). TTT was defined as the duration between tissue diagnosis and first treatment. Linear regression (β) was used to study the temporal trends in time delay.

RESULTS

A total of 239,638 patients were included. The median TTT was 25 days. Using multivariable analysis, we found that increasing age (OR 1.48), female gender (OR 1.04), Black race (OR 1.3), lower educational status (OR 1.2), Medicaid, Medicare insurance, and uninsured (OR 1.2, 1.5, and 1.2, respectively), treatment at academic centers (OR 1.3), higher Charlson-Deyo comorbidity index (OR 1.2), and CT/RT (OR 1.5) were associated with increased TTT. There was a steady rise in median TTT from 21 to 28 days between 2004 and 2020 (β = 0.3), suggestive of a worsening trend. Concurrently, there was an increasing trend in utilization of neoadjuvant CT/RT between 2004 and 2020 in early-stage PDAC. On Cox regression, TTT delay was associated with poor overall survival in stage I-IV patients (HR 1.1, 1.1, 1.09, and 1.53, respectively).

CONCLUSIONS

Delayed treatment approaching 2 months was observed in 10% of the population. The rising temporal trend in TTT may be attributed to the increasing shift toward neoadjuvant CT/RT in early-stage PDAC and/or the increasing use of tissue biopsy prior to surgery.

Comparing Time to Diagnosis and Treatment Between Younger and Older Adults With Colorectal Cancer: A Population-Based Study

BACKGROUND & AIMS

Younger adults (aged <50 years) with colorectal cancer (CRC) may have prolonged delays to diagnosis and treatment that are associated with adverse outcomes. We compared delay intervals by age for patients with CRC in a large population.

METHODS

This was a population-based study of adults diagnosed with CRC in Ontario, Canada, from 2003 to 2018. We measured the time between presentation and diagnosis (diagnostic interval), diagnosis and treatment start (treatment interval), and the time from presentation to treatment (overall interval). We compared interval lengths between adults aged <50 years, 50 to 74 years, and 75 to 89 years using multivariable quantile regression.

RESULTS

Included were 90,225 patients with CRC. Of these, 6853 patients (7.6%) were aged <50 years. Younger patients were more likely to be women, present emergently, have stage IV disease, and have rectal cancer compared with middle-aged patients. Factors associated with significantly longer overall intervals included female sex (8.7 days; 95% confidence interval [CI], 6.6-10.9 days) and rectal cancer compared with proximal colon cancer (9.8 days; 95% CI, 7.4-2.2 days). After adjustment, adults aged <50 years had significantly longer diagnostic intervals (4.3 days; 95% CI. 1.3-7.3 days) and significantly shorter treatment intervals (-4.5 days; 95% CI, -5.3 to -3.7 days) compared with middle-aged patients. However, there was no significant difference in the overall interval (-0.6 days; 95% CI, -4.3 to 3.2 days). In stratified models, younger adults with stage IV disease who presented emergently and patients aged >75 years had longer overall intervals.

CONCLUSIONS

Younger adults present more often with stage IV CRC but have overall similar times from presentation to treatment as screening-eligible older adults.

Impact of Access to Breast Care For West Texas Program on Early Detection and Regional Breast Cancer Mortality

INTRODUCTION

This study aimed to assess whether the Access to Breast Care for West Texas (ABC4WT) program impacted regional breast cancer detection and mortality in the Texas Council of Governments (COG)1 region.

METHODS

Interrupted time series analyses were utilized to evaluate the impact of the intervention. Spearman's rank correlation and cross-orrelation analyses were performed to assess the relationship between the total number of screenings and (i) the total number of breast cancer detected and (ii) the proportion of early-stage cancer detected and the (pre-whitened) residuals. A three-way interaction model compared pre-and post-intervention mortality in COG 1 with the COG 9 region (control).

RESULTS

Increased screening rate was associated with increased breast and early-stage cancer incidences (P = .001 and P = .002, respectively). There were significant positive cross-correlations between the total number of screenings and the total number of breast cancer detected (r = .996) and the proportion of early-stage cancer detected (r = .709) without a lag even after pre-whitening. Univariate analysis showed that regional mortality decreased with time (P < .001) and after intervention (P = .001). Multivariate analysis did not show any significant difference in time (P = .594), intervention (P = .453), and time and intervention interaction (P = .273). The three-way interaction model showed no difference in the baseline mortality and pre-intervention trend difference in COG 1 and COG 9 regions. However, there was a significant pre-post intervention trend difference in mortality COG 1 compared to the COG 9 region (P = .041).

CONCLUSION

Implementing the ABC4WT program was associated with the early detection of breast cancer and reducing regional mortality in the COG 1 region.

Small-Area Geographic and Socioeconomic Inequalities in Colorectal Cancer in Cyprus

Colorectal cancer (CRC) is one of the leading causes of death and morbidity worldwide. To date, the relationship between regional deprivation and CRC incidence or mortality has not been studied in the population of Cyprus. The objective of this study was to analyse the geographical variation of CRC incidence and mortality and its possible association with socioeconomic inequalities in Cyprus for the time period of 2000-2015. This is a small-area ecological study in Cyprus, with census tracts as units of spatial analysis. The incidence date, sex, age, postcode, primary site, death date in case of death, or last contact date of all alive CRC cases from 2000-2015 were obtained from the Cyprus Ministry of Health's Health Monitoring Unit. Indirect standardisation was used to calculate the sex and age Standardise Incidence Ratios (SIRs) and Standardised Mortality Ratios (SMRs) of CRC while the smoothed values of SIRs, SMRs, and Mortality to Incidence ratio (M/I ratio) were estimated using the univariate Bayesian Poisson log-linear spatial model. To evaluate the association of CRC incidence and mortality rate with socioeconomic deprivation, we included the national socioeconomic deprivation index as a covariate variable entering in the model either as a continuous variable or as a categorical variable representing quartiles of areas with increasing levels of socioeconomic deprivation. The results showed that there are geographical areas having 15% higher SIR and SMR, with most of those areas located on the east coast of the island. We found higher M/I ratio values in the rural, remote, and less dense areas of the island, while lower rates were observed in the metropolitan areas. We also discovered an inverted U-shape pattern in CRC incidence and mortality with higher rates in the areas classified in the second quartile (Q2-areas) of the socioeconomic deprivation index and lower rates in rural, remote, and less dense areas (Q4-areas). These findings provide useful information at local and national levels and inform decisions about resource allocation to geographically targeted prevention and control plans to increase CRC screening and management.

Measurement of clinical delay intervals among younger adults with colorectal cancer using health administrative data: a population-based analysis

BACKGROUND

Clinical delays may be important contributors to outcomes among younger adults (<50 years) with colorectal cancer (CRC). We aimed to describe delay intervals for younger adults with CRC using health administrative data to understand drivers of delay in this population.

METHODS

This was a population-based study of adults <50 diagnosed with CRC in Ontario, Canada from 2003 to 2018. Using administrative code-based algorithms (including billing codes), we identified four time points along the pathway to treatment-first presentation with a CRC-related symptom, first investigation, diagnosis date and treatment start. Intervals between these time points were calculated. Multivariable quantile regression was performed to explore associations between patient and disease factors with the median length of each interval.

RESULTS

6853 patients aged 15-49 were diagnosed with CRC and met the inclusion criteria. Males comprised 52% of the cohort, the median age was 45 years (IQR 40-47), and 25% had stage IV disease. The median time from presentation to treatment start (overall interval) was 109 days (IQR 55-218). Time between presentation and first investigation was short (median 5 days), as was time between diagnosis and treatment start (median 23 days). The greatest component of delay occurred between first investigation and diagnosis (median 78 days). Women, patients with distal tumours, and patients with earlier stage disease had significantly longer overall intervals.

CONCLUSIONS

Some younger CRC patients experience prolonged times from presentation to treatment, and time between first investigation to diagnosis was an important contributor. Access to endoscopy may be a target for intervention.

Clinical Delays and Comparative Outcomes in Younger and Older Adults with Colorectal Cancer: A Systematic Review

Outcome disparities between adults <50 with colorectal cancer (CRC) and older adults may be explained by clinical delays. This study synthesized the literature comparing delays and outcomes between younger and older adults with CRC. Databases were searched until December 2021. We included studies published after 1990 reporting delay in adults <50 that made comparisons to older adults. Comparisons were described narratively and stage between age groups was meta-analyzed. 39 studies were included representing 185,710 younger CRC patients and 1,422,062 older patients. Sixteen delay intervals were compared. Fourteen studies (36%) found significantly longer delays among younger adults, and nine (23%) found shorter delays among younger patients. Twelve studies compared time from symptom onset to diagnosis (N younger = 1538). Five showed significantly longer delays for younger adults. Adults <50 years also had higher odds of advanced stage (16 studies, pooled OR for Stage III/IV 1.76, 95% CI 1.52-2.03). Ten studies compared time from diagnosis to treatment (N younger = 171,726) with 4 showing significantly shorter delays for younger adults. All studies showing longer delays for younger adults examined pre-diagnostic intervals. Three studies compared the impact of delay on younger versus older adult. One showed longer delays were associated with advanced stage and worse survival in younger but not older adults. Longer delays among younger adults with CRC occur in pre-diagnostic intervals.

Treatment time interval in breast cancer: A population-based study on the impact of type and number of cancer centres attended

OBJECTIVES

We studied both the independent and combined effects of the places of biopsy and treatment on the treatment time interval based on a population-based study.

METHODS

We analysed the proportion of patients having a treatment time interval higher than the EUSOMA recommendation of 6 weeks, as a function of the number and the type of care centres the patients attended, from a French population-based regional cohort of women treated in 2015 for an incident invasive non-metastatic cancer (n = 505).

RESULTS

About 33% [95% CI: 27; 38] of patients had a treatment time interval higher than 6 weeks. About 48% of the patients underwent their biopsy and their initial treatment in the different centres. Results from multivariable analyses supported the impact of the type and number of centres attended on the proportion of time intervals over 6 weeks. This proportion was higher among patients with biopsy and treatment in different centres and among patients treated in a university hospital.

CONCLUSION

We pointed out the independent impact of the type and the number of care centres the patients attended, from biopsy to first treatment, on the treatment time interval, which is a well-known prognosis factor.

Time to diagnosis and treatment in younger adults with colorectal cancer: A systematic review

Background

The incidence of colorectal cancer is rising in adults <50 years of age. As a primarily unscreened population, they may have clinically important delays to diagnosis and treatment. This study aimed to review the literature on delay intervals in patients <50 years with colorectal cancer (CRC), and explore associations between longer intervals and outcomes.

Methods

MEDLINE, Embase, and LILACS were searched until December 2, 2021. We included studies published after 1990 reporting any delay interval in adults <50 with CRC. Interval measures and associations with stage at presentation or survival were synthesized and described in a narrative fashion. Risk of bias was assessed using the Newcastle-Ottawa Scale, Institute of Health Economics Case Series Quality Appraisal Checklist, and the Aarhus Checklist for cancer delay studies.

Results

55 studies representing 188,530 younger CRC patients were included. Most studies used primary data collection (64%), and 47% reported a single center. Sixteen unique intervals were measured. The most common interval was symptom onset to diagnosis (21 studies; N = 2,107). By sample size, diagnosis to treatment start was the most reported interval (12 studies; N = 170,463). Four studies examined symptoms onset to treatment start (total interval). The shortest was a mean of 99.5 days and the longest was a median of 217 days. There was substantial heterogeneity in the measurement of intervals, and quality of reporting. Higher-quality studies were more likely to use cancer registries, and be population-based. In four studies reporting the relationship between intervals and cancer stage or survival, there were no clear associations between longer intervals and adverse outcomes.

Discussion

Adults <50 with CRC may have intervals between symptom onset to treatment start greater than 6 months. Studies reporting intervals among younger patients are limited by inconsistent results and heterogeneous reporting. There is insufficient evidence to determine if longer intervals are associated with advanced stage or worse survival.

Other

This study’s protocol was registered with the Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42020179707).

A long waiting time from diagnosis to treatment decreases the survival of non-small cell lung cancer patients with stage IA1: A retrospective study

Objective

The prognostic effect of delayed treatment on stage IA1 non-small cell lung cancer (NSCLC) patients is still unclear. This study aimed to explore the association between the waiting time before treatment and the prognosis in stage IA1 NSCLC patients.

Methods

Eligible patients diagnosed with pathological stage IA1 NSCLC were included in this study. The clinical endpoints were overall survival (OS) and cancer-specific survival (CSS). The Kaplan-Meier method, the Log-rank test, univariable, and multivariable Cox regression analyses were used in this study. Propensity score matching was used to reduce the bias of data distribution.

Results

There were eligible 957 patients in the study. The length of waiting time before treatment stratified the survival in patients [&lt;3 months vs. ≥3-months, unadjusted hazard ratio (HR) = 0.481, P = 0.007; &lt;2 months vs. ≥2-months, unadjusted HR = 0.564, P = 0.006; &lt;1 month vs. ≥1-month, unadjusted HR = 0.537, P = 0.001]. The 5-year CSS rates were 95.0% and 77.0% in patients of waiting time within 3 months and over 3 months, respectively. After adjusting for other confounders, the waiting time was identified as an independent prognostic factor.

Conclusions

A long waiting time before treatment may decrease the survival of stage IA1 NSCLC patients. We propose that the waiting time for those patients preferably is less than one month and should not exceed two months.

A comparison of liver MRI and contrast enhanced CT as standard workup before treatment for rectal cancer in usual care - a Retrospective Study

BACKGROUND

The liver is the most common site for rectal cancer metastases. Recommended standard pre-treatment workup has involved computed tomography (CT) for abdominal metastases. However, few hospitals have replaced this with magnetic resonance imaging (MRI).

INTRODUCTION

The aim of this study was to compare MRI with CT as an index examination of the liver in the pre-treatment workup in usual care. The primary endpoint was the need for supplementary liver investigations.

METHOD

Consecutive patients from two hospitals during 2013-2015 were identified in the Regional Swedish Colorectal Cancer Register and included in this retrospective study. Hospital records and radiology reports were reviewed. Inconclusive reports were re-evaluated by two radiologists.

RESULT

A total of 320 patients were included, and 293 were available for analysis. Some 175 and 118 patients had undergone CT and MRI, respectively, as their index pretreatment liver examination. Thirty-four (19.4%) in the CT group and 6 (5.1%) patients in the MRI group underwent supplementary liver investigation due to inconclusive index examination (RR 3.82, 95% CI: 1.66;8.81, p=0.0017). Median time (q1;q3) from index examination to start of treatment was 50 (36;68) days in the CT group and 34 (27;45) days in the MRI group.

CONCLUSION

This retrospective study of two modalities within usual care found that MRI of the liver as index radiological workup before treatment for rectal cancer was associated with fewer supplementary liver investigations and a shorter time to start treatment. Based on these findings, a prospective trial should be undertaken before implementing MRI as a standard.

Conflicting Guidelines: A Systematic Review on the Proper Interval for Colorectal Cancer Treatment

BACKGROUND

Timely treatment for colorectal cancer (CRC) is a quality indicator in oncological care. However, patients with CRC might benefit more from preoperative optimization rather than rapid treatment initiation. The objectives of this study are (1) to determine the definition of the CRC treatment interval, (2) to study international recommendations regarding this interval and (3) to study whether length of the interval is associated with outcome.

METHODS

We performed a systematic search of the literature in June 2020 through MEDLINE, EMBASE and Cochrane databases, complemented with a web search and a survey among colorectal surgeons worldwide. Full-text papers including subjects with CRC and a description of the treatment interval were included.

RESULTS

Definition of the treatment interval varies widely in published studies, especially due to different starting points of the interval. Date of diagnosis is often used as start of the interval, determined with date of pathological confirmation. The end of the interval is rather consistently determined with date of initiation of any primary treatment. Recommendations on the timeline of the treatment interval range between and within countries from two weeks between decision to treat and surgery, to treatment within seven weeks after pathological diagnosis. Finally, there is no decisive evidence that a longer treatment interval is associated with worse outcome.

CONCLUSIONS

The interval from diagnosis to treatment for CRC treatment could be used for prehabilitation to benefit patient recovery. It may be that this strategy is more beneficial than urgently proceeding with treatment.

A Comparison of CT Manifestations between Coronavirus Disease 2019 (COVID-19) and Other Types of Viral Pneumonia

BACKGROUND

Though imaging manifestations of COVID-19 and other types of viral pneumonia are similar, their clinical treatment methods differ. Accurate, non-invasive diagnostic methods using CT imaging can help developing an optimal therapeutic regimen for both conditions.

OBJECTIVES

To compare the initial CT imaging features in COVID-19 with those in other types of viral pneumonia.

METHODS

Clinical and imaging data of 51 patients with COVID-19 and 69 with other types of viral pneumonia were retrospectively studied. All significant imaging features (Youden index >0.3) were included for constituting the combined criteria for COVID-19 diagnosis, composed of two or more imaging features with a parallel model. McNemar's chi-square test or Fisher's exact test was used to compare the validity indices (sensitivity and specificity) among various criteria.

RESULTS

Ground glass opacities (GGO) dominated density, peripheral distribution, unilateral lung, clear margin of lesion, rounded morphology, long axis parallel to the pleura, vascular thickening, and crazy-paving pattern were more common in COVID-19 (p <0.05). Consolidation-dominated density, both central and peripheral distribution, bilateral lung, indistinct margin of lesion, tree-in-bud pattern, mediastinal or hilar lymphadenectasis, pleural effusion, and pleural thickening were more common in other types of viral pneumonia (p < 0.05). GGO-dominated density or long axis parallel to the pleura (with the highest sensitivity), and GGO-dominated density or long axis parallel to the pleura or vascular thickening (with the highest specificity) are good combined criteria of COVID-19.

CONCLUSION

The initial CT imaging features are helpful for differential diagnosis between COVID-19 and other types of viral pneumonia.

Do mobile units contribute to spatial accessibility to mammography for uninsured women?

Limited spatial accessibility to mammography, and socioeconomic barriers (e.g., being uninsured), may contribute to rural disparities in breast cancer screening. Although mobile mammography may contribute to population-level access, few studies have investigated this relationship. We measured mammography access for uninsured women using the variable two-step floating catchment area (V2SFCA) method, which estimates access at the local level using estimated potential supply and demand. Specifically, we measured supply with mammography machine certifications in 2014 from FDA and brick-and-mortar and mobile facility data from the community-based Breast Screening and Patient Navigation (BSPAN) program. We measured potential demand using Census tract-level estimates of female residents aged 45-74 from 5-year 2012-2016 American Community Survey data. Using the sign test, we compared mammography access estimates based on 3 facility groupings: FDA-certified, program brick-and-mortar only, and brick-and-mortar plus mobile. Using all mammography facilities, accessibility was high in urban Dallas-Ft. Worth, low for the ring of adjacent counties, and high for rural counties outlying this ring. Brick-and-mortar-based estimates were lower for the outlying ring, and mobile-unit contribution to access was observed more in urban tracts. Weak mobile-unit contribution across the study area may indicate suboptimal dispatch of mobile units to locations. Geospatial methods could identify the optimal locations for mobile units, given existing brick-and-mortar facilities, to increase access for underserved areas.

Extent of disease at first cancer presentation and previous anxiety and depressive symptoms: the HUNT study

BACKGROUND

Depressive symptoms are associated with higher cancer mortality, whereas anxiety symptoms are associated with lower than expected risk.

AIMS

This study aimed to investigate the prospective association between depressive/anxiety symptoms and the extent of disease (EOD) of first cancer at diagnosis.

METHOD

Prospective population-based study conducted from the second wave of the Nord-Trøndelag Health (HUNT) study. Of 65 000 residents comprehensively interviewed and examined for health status, 407 received first lifetime cancer diagnoses 1-3 years later, ascertained from the Cancer Registry of Norway, and had EOD recorded. Patients with localised disease or regional/distant spread at cancer diagnosis were analysed for earlier depressive/anxiety symptoms ascertained by the Hospital Anxiety and Depression Scale in HUNT.

RESULTS

Beyond-local EOD was present in 59.8% of those with neither anxiety nor depression, in 76.6% of those with depression alone (odds ratio, 2.20; 1.08-4.49), in 39.3% of those with anxiety alone (odds ratio, 0.44; 0.20-0.96) and in 57.7% of those with both anxiety and depression (odds ratio, 0.92; 0.41-2.06). After adjustment for demographic and health status, and cancer type, these associations were marginally stronger, but no longer statistically significant (odds ratios, 2.26; 0.84-6.11; 0.43; 0.15-1.26; and 1.00; 0.98-1.03, respectively).

CONCLUSIONS

In people who develop cancer, beyond-local EOD at diagnosis was more common in people with previous depression and less common in people with previous anxiety; however, independence from confounding factors could not be concluded.

Comparing Pathways to Diagnosis and Treatment for Rural and Urban Patients With Colorectal or Breast Cancer: A Qualitative Study

PURPOSE

Colorectal cancer patients living in rural areas have poorer outcomes than urban counterparts, but such disparities are not found for breast cancer. Although time to care may contribute to rural-urban disparities, few studies examine patient experiences to understand how and why delays may occur. We compared rural and urban patient experiences of pathways to colorectal or breast cancer diagnosis and treatment in Victoria, Australia.

METHODS

Semistructured telephone interviews were conducted with 43 patients (49% colorectal; 60% rural, median 7 months postdiagnosis). A framework analysis was applied using the Model of Pathways to Treatment.

FINDINGS

Rural and urban patients expressed similar attitudes and reasons for prolonged symptom appraisal and help-seeking triggers. However, some rural patients reported long waiting times to see a Primary Care Practitioner (PCP) and perceived greater gatekeeping to diagnostic services. Patient perceptions of the urgency of PCP referral could impact behavior, such as waiting longer to book appointments. Colorectal cancer patients reported more variable types of symptoms, interpretation, and coping strategies, as well as diverse presentation routes and reduced sense of urgency, compared to breast cancer patients. Waiting time for colonoscopy could be long, particularly in the public health system, but mammograms were quickly arranged.

CONCLUSIONS

Pathway variation was more evident by cancer type than residential location. However, access to primary care and diagnostic services for rural patients with colorectal cancer may be important policy targets. Future research should investigate the impact of diagnostic service accessibility on PCP referral behavior to further understand rural-urban disparities.

Breast Cancer Presentation, Surgical Management and Mortality Across the Rural-Urban Continuum in the National Cancer Database

OBJECTIVE

The purpose of this study was to examine differences in presentation, surgical management, and mortality among breast cancer patients in the National Cancer Database (NCDB) based on area of residence.

METHODS

The NCDB was queried for women with a diagnosis of breast cancer from 1 January 2004-31 December 2015. The data were divided by metropolitan (large, medium, small) and non-metropolitan (urban, rural) status.

RESULTS

Cancer stage increased with rurality (p < 0.0001). Residency in a large metropolitan area was associated with increased breast reconstruction rates (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.19-1.30) and reduced overall mortality (hazard ratio 0.92, 95% CI 0.89-0.95) compared with rural areas. There was no difference in mastectomy use among small metropolitan (OR 1.03, 95% CI 1.01-1.04), urban (OR 0.99, 95% CI 0.98-1), and rural areas (OR 1.05, 95% CI 1.01-1.07) compared with large metropolitan areas.

CONCLUSIONS

Across the rural-urban continuum in the NCDB, stage of cancer presentation increased with rurality. Conversely, residency in a large metropolitan area was associated with higher reconstruction rates and a reduction in overall mortality. Future studies should evaluate factors contributing to advanced disease presentation and lower reconstruction rates among rural breast cancer patients.

The effect of diagnostic delay attributable to the healthcare system on the prognosis of colorectal cancer

OBJECTIVES

To analyse the effect of a delay attributable to the healthcare system on a consecutive cohort of outpatients diagnosed with colorectal cancer in the healthcare area of Ourense (Spain).

PATIENTS AND METHODS

We performed a retrospective cohort study that included patients diagnosed between 2009 and 2017. Delay attributable to the healthcare system was defined as the time between the first consultation with symptoms and the diagnostic confirmation. A logistic regression model was performed to evaluate the relationship between stage IV CRC and diagnostic delay. To analyse which variables were associated independently with overall mortality and mortality due to CRC we used a Cox regression model.

RESULTS

575 patients were included (men 64.5%, age 71.9 ± 11.5 years), with a delay attributable to the healthcare system of 115 ± 153 days. None of the variables analysed were associated with tumour stage at diagnosis. With a mean follow-up of 30.6 ± 21 months, 121 patients died (79.3% due to CRC). The variables independently associated with CRC-related mortality were metastatic CRC (HR 50.65, 95% CI 12.28-209), age (HR 1.04, 95% CI 1.02-1.05) and colonoscopy requested from the Primary Healthcare level (HR 0.55, 95% CI 0.36-0.88).

CONCLUSIONS

Diagnostic delay attributable to the healthcare system is not related to the prognosis or stage of CRC. However, a direct referral to colonoscopy from the Primary Healthcare level reduces the risk of mortality in our patients.

Relationship between preexisting mental disorders and prognosis of gynecologic cancers: A case-control study

AIM

Cancer treatment involves long-term therapy and follow-up, with mental disorders (MD) often affecting the treatment process. Hence, in this study, we retrospectively analyze cases involving gynecologic cancer with MD and clarify the relationship between psychosis and cancer prognosis.

METHODS

Patients with both gynecologic cancer and MD from January 2003 to August 2016 were recruited in this study. Cases were limited to those whose MD had been diagnosed before their cancer. Control patients without MD were also analyzed. Both cases and controls were adjusted for age, cancer type, and cancer stage.

RESULTS

A total of 54 patients with gynecologic cancer and MD, as well as 108 controls without MD, were included. The median age of the patients was 52 years. Details regarding cancer type were as follows: 11 ovarian cancers, 26 uterine corpus cancers and 17 cervical cancers. Among these, 25 schizophrenia cases, 15 depressive disorders, 4 bipolar disorders and 10 other MD were recorded. No significant differences in the 5-year survival rate were found between patients and controls. In advanced-stage cervical cancer, however, the prognosis was significantly poor given the low rate of initial treatment completion. Moreover, patients with advanced-stage cervical cancer had significantly lower chemotherapy completion rates compared to those with other gynecologic malignancies.

CONCLUSION

Mental disorders do not affect the prognosis of gynecologic cancers, except for advanced cervical cancer. Accordingly, improving the low rate of initial treatment completion seems to be a focal point for better prognosis in advanced cervical cancer.

Suicide attempts by jumping and length of stay in general hospital: A retrospective study of 225 patients

OBJECTIVE

Violent suicide attempts, such as jumping from a height, frequently lead to hospitalization in general hospital with high length of stay (LOS). We investigated features associated with LOS in this context.

METHODS

We retrospectively included all patients admitted after suicide attempts by jumping in non-psychiatric wards of a university hospital between 2008 and 2016. Several socio-demographic and clinical data were collected, including psychiatric diagnoses, coded with the International Classification of Diseases-10th Revision. We used general linear models to identify factors associated with LOS.

RESULTS

Among 225 patients (125 men; mean age ± sd: 37.5 ± 15.4 years), several clinical factors were independently associated with a longer LOS: number of injuries (β = 8.2 p < .001), external fixator (β = 18.1 p = .01), psychotic disorder (β = 14.6 p = .02) and delirium (β = 16.6 p = .005). Admission in psychiatric ward at discharge tended to be associated with lower LOS (β = -15.3 p = .07).

CONCLUSION

In patients admitted in non-psychiatric wards after suicide attempt by jumping, the presence of a psychotic disorder may increase LOS by several days, and indirectly costs of hospitalization, to a similar extent of non-psychiatric factors. The association of transfer in psychiatric ward with lower LOS suggests that the psychiatric disorder might interfere with medical care.

Locally advanced breast cancer in young women in Latin America

The purpose of this review is to organise, summarise and critically assess existing knowledge on locally advanced breast cancer (LABC) among young women in Latin America. We discuss the most relevant findings in six sections: 1) epidemiology of breast cancer in young women in Latin America; 2) being young as a factor for worse prognosis; 3) LABC in young women in the region; 4) aggressive tumour behaviour among young women; 5) delays in diagnosis and treatment and 6) burden of advanced disease. We point out the need to dedicate resources to enhance earlier diagnosis and prompt referrals of young women with breast cancer; promote research regarding prevalence, biologic characteristics, outcomes and reasons for diagnosis and treatment delays for this age group; and finally, implement supportive care programmes as a means of improving patients and their families’ well-being. The recognition of the current standpoint of breast cancer in young patients across the continent should shed some light on the importance of this pressing matter.

Depressive Symptom Profiles and Survival in Older Patients with Cancer: Latent Class Analysis of the ELCAPA Cohort Study

BACKGROUND

The expression of depressive symptoms in older people with cancer is heterogeneous because of specific features of age or cancer comorbidity. We aimed to identify depressive symptom profiles in this population and describe the associated features including survival.

MATERIALS AND METHODS

Patients ≥70 years who were referred to geriatric oncology clinics were prospectively included in the ELCAPA study. In this subanalysis, depressive symptoms were used as indicators in a latent class analysis. Multinomial multivariable logistic regression and Cox models examined the association of each class with baseline characteristics and mortality.

RESULTS

For the 847 complete-case patients included (median age, 79 years; interquartile range, 76-84; women, 47.9%), we identified five depressive symptom classes: "no depression/somatic only" (38.8%), "no depression/pauci-symptomatic" (26.4%), "severe depression" (20%), "mild depression" (11.8%), and "demoralization" (3%). Compared with the no depression/pauci-symptomatic class, the no depression/somatic only and severe depression classes were characterized by more frequent comorbidities with poorer functional status and higher levels of inflammation. "Severe" and "mild" depression classes also featured poorer nutritional status, more medications, and more frequent falls. Severe depression was associated with poor social support, inpatient status, and increased risk of mortality at 1 year (adjusted hazard ratio, 1.62, 95% confidence interval, 1.06-2.48) and 3 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.06-2.10).

CONCLUSION

A data-driven approach based on depressive symptoms identified five different depressive symptom profiles, including demoralization, in older patients with cancer. Severe depression was independently and substantially associated with poor survival.

IMPLICATIONS FOR PRACTICE

Older patients with cancer present with distinct profiles of depressive symptomatology, including different severity levels of depression and the demoralization syndrome. Clinicians should use a systematic assessment of depressive symptoms to adequately highlight these distinct profiles. Geriatric and oncological features are differently associated with these profiles. For instance, severe depression was associated with more frequent comorbidities with poorer functional, poor nutritional status, polypharmacy, frequent falls, inpatient status and poor social support. Also, severe depression was independently and substantially associated with poor survival so that the identification and management of depression should be considered a high priority in this population.

Hospital transfer after a breast cancer diagnosis: A population-based study in the Netherlands of the extent, predictive characteristics and its impact on time to treatment

PURPOSE

Patients may transfer of hospital for clinical reasons but this may delay time to treatment. The purpose of this study is to provide insight in the extent of hospital transfer in breast cancer care; which type of patients transfer and what is the impact on time to treatment.

METHODS

We included 41,413 breast cancer patients registered in the Netherlands Cancer Registry between 2014 and 2016. We investigated transfer of hospital between diagnosis and first treatment being surgery or neoadjuvant chemotherapy (NAC). Co-variate adjusted characteristics predictive for hospital transfer were determined. To adjust for possible treatment by indication bias we used propensity score matching (PSM). Time to treatment in patients with and without hospital transfer was compared.

RESULTS

Among 41,413 patients, 8.5% of all patients transferred to another hospital between diagnosis and first treatment; 4.9% before primary surgery and 24.8% before NAC. Especially young (aged <40 years) patients and those who underwent a mastectomy with immediate breast reconstruction (IBR) were more likely to transfer. The association of mastectomy with IBR with hospital transfer remained when using PSM. Hospital transfer after diagnosis significantly prolonged time to treatment; breast-conserving surgery by 5 days, mastectomy by 7 days, mastectomy with IBR by 9 days and NAC by 1 day.

CONCLUSIONS

While almost 5% of Dutch patients treated with primary surgery transfer hospital after diagnosis and up to 25% for patients treated with NAC, our findings suggest that especially those treated with primary surgery are at risk for additional treatment delay by hospital transfer.

Patterns of Care of Breast Cancer Patients in a Rural Cancer Center in Western India

Breast cancer is an emerging public health problem in low- and middle-income countries. The main objective is to describe the clinical characteristics and patterns of care of breast cancer patients diagnosed and treated in a rural cancer hospital in Barshi, Western India. The results from a cross-sectional study of 99 consecutive breast cancer patients diagnosed and treated between February 2012 and November 2014 in Nargis Dutt Memorial Cancer Hospital is reported. The case records of the patients were scrutinized and reviewed to abstract data on their clinical characteristics, diagnostic, and treatment details. The mean age at diagnosis of the patients was 52.8 ± 11.6 years; 83.5% of women were married, and 60.6% were illiterate. Sixty percent of patients had tumors measuring 5 cm or less. Almost half of the patients (46.4%) had stage I or II A disease and a third (36.0%) had axillary lymph node metastasis. Estrogen, progesterone, and human epidermal growth factor receptor2 receptor status were investigated in 41 (41.4%) of patients only. The median interval between diagnosis and initiation of treatment was 11 days. Modified radical mastectomy was done in 91% of patients, and nearly a third of patients who were prescribed chemotherapy did not complete treatment. The rural-based tertiary cancer care center has made treatment more accessible to breast cancer patients and has reduced the interval between diagnosis and treatment initiation. However, there are still many challenges like non-compliance to and incomplete treatments and poor follow-up that need to be addressed.

Physician peer group characteristics and timeliness of breast cancer surgery

PURPOSE

Little is known about how the structure of interdisciplinary groups of physicians affects the timeliness of breast cancer surgery their patients receive. We used social network methods to examine variation in surgical delay across physician peer groups and the association of this delay with group characteristics.

METHODS

We used linked Surveillance, Epidemiology, and End Results-Medicare data to construct physician peer groups based on shared breast cancer patients. We used hierarchical generalized linear models to examine the association of three group characteristics, patient racial composition, provider density (the ratio of potential vs. actual connections between physicians), and provider transitivity (clustering of providers within groups), with delayed surgery.

RESULTS

The study sample included 8338 women with breast cancer in 157 physician peer groups. Surgical delay varied widely across physician peer groups (interquartile range 28.2-50.0%). For every 10% increase in the percentage of black patients in a peer group, there was a 41% increase in the odds of delayed surgery for women in that peer group regardless of a patient's own race [odds ratio (OR) 1.41, 95% confidence interval (CI) 1.15-1.73]. Women in physician peer groups with the highest provider density were less likely to receive delayed surgery than those in physician peer groups with the lowest provider density (OR 0.65, 95% CI 0.44-0.98). We did not find an association between provider transitivity and delayed surgery.

CONCLUSIONS

The likelihood of surgical delay varied substantially across physician peer groups and was associated with provider density and patient racial composition.

How Long Are Cancer Patients Waiting for Oncological Therapy in Poland?

Background: The five-year relative survival rate in Poland is approximately 10% lower compared with the average for Europe. One of the factors that may contribute to the inferior treatment results in Poland could be the long time between cancer suspicion and the beginning of treatment. The aim of the study was to determine the real waiting time for cancer diagnosis and treatment in Poland. Methods: The study was carried out in six cancer centers on a group of 1373 patients, using a questionnaire to interview patients. The median waiting time was estimated as follows: (A) from suspicion (the date of the first visit, with symptoms, to a doctor or a preventive or screening test) until histopathological diagnosis; (B) from suspicion until initial treatment; and (C) from diagnosis until initial treatment. Results: The median times from suspicion to treatment, from suspicion to diagnosis, and from diagnosis to treatment, were 10.6, 5.6, and 5.0 weeks, respectively. Using multivariate analysis, the strongest influence was estimated, in a case of tumor localization, to be the method of initial treatment and facilities. Conclusion: The waiting time for cancer treatment in Poland is too long. The highest influence on waiting time was determined, in the case of tumors, as the type of cancer and factors related to the health care system.

Time to diagnosis and treatment for cancer patients in the Netherlands: Room for improvement?

BACKGROUND & AIM

Reducing the duration of the diagnostic cancer care pathway is intensively pursued. The aim of this study was to chart the diagnostic pathway for the five most common cancers in the Netherlands.

METHODS

A retrospective cohort study using cancer patients' anonymised primary care data (free text and coded) linked to the Netherlands Cancer Registry. We determined the median duration of the following: 1. Primary care intervals (IPCs): the first cancer-related general practitioner consultation to referral, 2. Referral intervals (IRs): referral to diagnosis, 3. Treatment intervals (ITs): diagnosis to treatment and the overarching intervals, 4. Diagnostic intervals (IDs): IPC and IR combined and 5. Health care intervals (IHCs): IPC, IR and IT combined.

RESULTS

For 465, 309, 197, 237 and 149 patients diagnosed with breast-, colorectal-, lung-, prostate cancer and melanoma, respectively; median IPC, IR and ID durations were shortest for breast cancer and melanoma (ID duration 7 and 21 days, respectively), intermediate for lung- and colon cancer (ID duration 49 and 54 days) and the longest for prostate cancer (ID duration 137 days). For all cancers, the duration of intervals increased steeply for the 10-25% with longest durations. For colorectal cancer, increasing ID durations showed increasing proportions of time attributable to primary care (IPC).

CONCLUSION

Approximately 10-25% of cancer patients show substantially long duration of diagnostic intervals. Reducing primary care delay seems particularly relevant for colorectal cancer.

Factors influencing time to seeking medical advice and onset of treatment in women who are diagnosed with breast cancer in Serbia

OBJECTIVE

Streamlining the diagnosis is a key factor in improving the treatment outcomes for breast cancer. The aim of this study was to determine factors influencing time to seeking medical advice and treatment onset in women who are diagnosed with breast cancer in Serbia.

METHODS

The study was a multicenter, cross-sectional national survey, performed at 10 oncology centers in Serbia. Time intervals spent throughout the complex diagnostic pathway were evaluated using a validated questionnaire administered to women with breast cancer (n = 800). Total interval (TI) was determined using predefined time scales, including one referring to patient interval (PI), and several related to health care system interval (SI).

RESULTS

Mean PI, SI, and TI were 4.5, 9.2, and 12.9 weeks, respectively; 20% of patients had a PI>12 weeks. Based on the multivariate regression model, longer PI was associated with perceived lack of time and personal disregard or trivialization of detected symptoms and signs. Women who were supported by family members or friends and had at least a secondary level education tended to have a shorter PI. Longer PI was correlated with a longer SI, while regular self-examination, having been diagnosed by an oncologist, and living in a major city were associated with shorter SI.

CONCLUSIONS

Several factors, related to psychological, demographic, behavioral, and health system characteristics, determined both the time to seeking medical advice and treatment onset for breast cancer. These findings support review and refining of national strategies and policies to promote early detection, diagnosis, and treatment of breast cancer.

Evidence of advanced stage colorectal cancer with longer diagnostic intervals: a pooled analysis of seven primary care cohorts comprising 11 720 patients in five countries

BACKGROUND

The benefits from expedited diagnosis of symptomatic cancer are uncertain. We aimed to analyse the relationship between stage of colorectal cancer (CRC) and the primary and specialist care components of the diagnostic interval.

METHODS

We identified seven independent data sets from population-based studies in Scotland, England, Canada, Denmark and Spain during 1997-2010 with a total of 11 720 newly diagnosed CRC patients, who had initially presented with symptoms to a primary care physician. Data were extracted from patient records, registries, audits and questionnaires, respectively. Data sets were required to hold information on dates in the diagnostic interval (defined as the time from the first presentation of symptoms in primary care until the date of diagnosis), symptoms at first presentation in primary care, route of referral, gender, age and histologically confirmed stage. We carried out reanalysis of all individual data sets and, using the same method, analysed a pooled individual patient data set.

RESULTS

The association between intervals and stage was similar in the individual and combined data set. There was a statistically significant convex (∩-shaped) association between primary care interval and diagnosis of advanced (i.e., distant or regional) rather than localised CRC (P=0.004), with odds beginning to increase from the first day on and peaking at 90 days. For specialist care, we saw an opposite and statistically significant concave (∪-shaped) association, with a trough at 60 days, between the interval and diagnosis of advanced CRC (P<0.001).

CONCLUSIONS

This study provides evidence that longer diagnostic intervals are associated with more advanced CRC. Furthermore, the study cannot define a specific 'safe' waiting time as the length of the primary care interval appears to have negative impact from day one.

A cancer geography paradox? Poorer cancer outcomes with longer travelling times to healthcare facilities despite prompter diagnosis and treatment: a data-linkage study

BACKGROUND

Rurality and distance from cancer treatment centres have been shown to negatively impact cancer outcomes, but the mechanisms remain obscure.

METHODS

We analysed the impact of travel time to key healthcare facilities and mainland/island residency on the cancer diagnostic pathway (treatment within 62 days of referral, and within 31 days of diagnosis) and 1-year mortality using a data-linkage study with 12 339 patients.

RESULTS

After controlling for important confounders, mainland patients with more than 60 min of travelling time to their cancer treatment centre ((OR 1.42; 95% CI 1.25-1.61) and island dwellers (OR 1.32; 95% CI 1.09-1.59) were more likely to commence cancer treatment within 62 days of general practitioner (GP) referral and within 31 days of their cancer diagnosis compared with those living within 15 min. Island-dweller patients were more likely to have their diagnosis and treatment started on the same or next day (OR 1.72; 95% CI 1.31-2.25). Increased travelling time to a cancer treatment centre was associated with increased mortality to 1 year (30-59 min (HR 1.21; 95% CI 1.05-1.41), >60 min (HR 1.18; 95% CI 1.03-1.36), island dweller (HR 1.17; 95% CI 0.97-1.41).

CONCLUSIONS

Island dwelling and greater mainland travel burden was associated with more rapid cancer diagnosis and treatment following GP referral even after adjustment for advanced disease; however, these patients also experienced a survival disadvantage compared with those living nearer. Cancer services may need to be better configured to suit the different needs of dispersed populations.

Impact of travel time and rurality on presentation and outcomes of symptomatic colorectal cancer: a cross-sectional cohort study in primary care

BACKGROUND

Several studies have reported a survival disadvantage for rural dwellers who develop colorectal cancer, but the underlying mechanisms remain obscure. Delayed presentation to GPs may be a contributory factor, but evidence is lacking.

AIM

To examine the association between rurality and travel time on diagnosis and survival of colorectal cancer in a cohort from northeast Scotland.

DESIGN AND SETTING

The authors used a database linking GP records to routine data for patients diagnosed between 1997 and 1998, and followed up to 2011.

METHOD

Primary outcomes were alarm symptoms, emergency admissions, stage, and survival. Travel time in minutes from patients to GP was estimated. Logistic and Cox regression were used to model outcomes. Interaction terms were used to determine if travelling time impacted differently on urban versus rural patients.

RESULTS

Rural patients and patients travelling farther to the GP had better 3-year survival. When the travel outcome associations were explored using interaction terms, the associations differed between rural and urban areas. Longer travel in urban areas significantly reduced the odds of emergency admissions (odds ratio [OR] 0.62, P<0.05), and increased survival (hazard ratio 0.75, P<0.05). Longer travel also increased the odds of presenting with alarm symptoms in urban areas; this was nearly significant (OR 1.34, P = 0.06). Presence of alarm symptoms reduced the likelihood of emergency admissions (OR 0.36, P<0.01).

CONCLUSION

Living in a rural area, and travelling farther to a GP in urban areas, may reduce the likelihood of emergency admissions and poor survival. This may be related to how patients present with alarm symptoms.

Comorbid conditions delay diagnosis of colorectal cancer: a cohort study using electronic primary care records

BACKGROUND

Pre-existing non-cancer conditions may complicate and delay colorectal cancer diagnosis.

METHOD

Incident cases (aged ⩾40 years, 2007-2009) with colorectal cancer were identified in the Clinical Practice Research Datalink, UK. Diagnostic interval was defined as time from first symptomatic presentation of colorectal cancer to diagnosis. Comorbid conditions were classified as 'competing demands' (unrelated to colorectal cancer) or 'alternative explanations' (sharing symptoms with colorectal cancer). The association between diagnostic interval (log-transformed) and age, gender, consultation rate and number of comorbid conditions was investigated using linear regressions, reported using geometric means.

RESULTS

Out of the 4512 patients included, 72.9% had ⩾1 competing demand and 31.3% had ⩾1 alternative explanation. In the regression model, the numbers of both types of comorbid conditions were independently associated with longer diagnostic interval: a single competing demand delayed diagnosis by 10 days, and four or more by 32 days; and a single alternative explanation by 9 days. For individual conditions, the longest delay was observed for inflammatory bowel disease (26 days; 95% CI 14-39).

CONCLUSIONS

The burden and nature of comorbidity is associated with delayed diagnosis in colorectal cancer, particularly in patients aged ⩾80 years. Effective clinical strategies are needed for shortening diagnostic interval in patients with comorbidity.

Timing of Breast Cancer Surgery-How Much Does It Matter?

Timing of surgical resection after breast cancer diagnosis is dependent on a variety of factors. Lengthy delays may lead to progression; however, the impact of modest delays is less clear. The aim of this study was to evaluate the impact of surgical timing on outcomes, including disease-free survival (DFS) and nodal status (NS). The cancer registry from one academic cancer hospital was retrospectively reviewed. Time from initial biopsy to surgical resection was calculated for patients with ductal carcinoma in situ (DCIS) and stage 1 and 2 invasive carcinomas. Early (0-21 days), intermediate (22-42 days), and late (43-63 days) surgery groups were evaluated for differences in NS and DFS for each cancer stage separately. A total of 3,932 patients were identified for analysis. There were no differences in DFS noted for DCIS. For stage 1, early surgery (ES) was associated with worse DFS compared to intermediate surgery (IS) (p = 0.025). There were no significant differences between ES and late surgery (LS) (p = 0.700) or IS and LS (p = 0.065). In stage II cancers, there was a significant difference in DFS in ES compared to IS (p < 0.001) and LS (p = 0.009). There was no significant difference between IS and LS (p = 0.478). Patients were more likely to undergo immediate reconstruction (p < 0.0001 for all stages) in later time-to-surgery groups, while patients in earlier groups were more likely to undergo breast conserving surgery. There was also no significant difference in NS at time of surgery in clinical stage 1 (p = 0.321) or stage 2 disease (p = 0.571). Delays of up to 60 days were not associated with worse outcomes. This study should reassure patients and surgeons that modest delays do not adversely affect breast cancer outcomes. This allows patients time to consider treatment and reconstruction options.

Factors associated with mode of colorectal cancer detection and time to diagnosis: a population level study

Background

Although it is well-known that early detection of colorectal cancer (CRC) is important for optimal patient survival, the relationship of patient and health system factors with delayed diagnosis are unclear. The purpose of this study was to identify the demographic, clinical and healthcare factors related to mode of CRC detection and length of the diagnostic interval.

Methods

All residents of Alberta, Canada diagnosed with first-ever incident CRC in years 2004–2010 were identified from the Alberta Cancer Registry. Population-based administrative health datasets, including hospital discharge abstract, ambulatory care classification system and physician billing data, were used to identify healthcare services related to CRC diagnosis. The time to diagnosis was defined as the time from the first CRC-related healthcare visit to the date of CRC diagnosis. Mode of CRC detection was classified into three groups: urgent, screen-detected and symptomatic. Quantile regression was performed to assess factors associated with time to diagnosis.

Results

9626 patients were included in the study; 25% of patients presented as urgent, 32% were screen-detected and 43% were symptomatic. The median time to diagnosis for urgent, screen-detected and symptomatic patients were 6 days (interquartile range (IQR) 2–14 days), 74 days (IQR 36–183 days), 84 days (IQR 39–223 days), respectively. Time to diagnosis was greater than 6 months for 27% of non-urgent patients. Healthcare factors had the largest impact on time to diagnosis: 3 or more visits to a GP increased the median by 140 days whereas 2 or more visits to a GI-specialist increased it by 108 days compared to 0–1 visits to a GP or GI-specialist, respectively.

Conclusion

A large proportion of CRC patients required urgent work-up or had to wait more than 6 months for diagnosis. Actions are needed to reduce the frequency of urgent presentation as well as improve the timeliness of diagnosis. Findings suggest a need to improve coordination of care across multiple providers.

Are disparities of waiting times for breast cancer care related to socio-economic factors? A regional population-based study (France)

The increasing number of breast cancer cases may induce longer waiting times (WT), which can be a source of anxiety for patients and may play a role in survival. The aim of this study was to examine the factors, in particular socio-economic factors, related to treatment delays. Using French Cancer Registry databases and self-administered questionnaires, we included 1,152 women with invasive non-metastatic breast cancer diagnosed in 2007. Poisson regression analysis was used to identify WTs' influencing factors. For 973 women who had a malignant tissue sampling, the median of overall WT between the first imaging procedure and the first treatment was 44 days (9 days for pathological diagnostic WT and 31 days for treatment WT). The medical factors mostly explained inequalities in WTs. Socio-economic and behavioral factors had a limited impact on WTs except for social support which appeared to be a key point. Better identifying the factors associated with increase in WTs will make it possible to develop further interventional or prospective studies to confirm their causal role in delay and at last reduce disparities in breast cancer management.

Time-to-Surgery and Survival Outcomes in Resectable Colorectal Liver Metastases: A Multi-Institutional Evaluation

BACKGROUND

Resection of colorectal liver metastases (CRLM) is associated with improved survival; however, the impact of time to resection on survival is unknown. The current multi-institutional study sought to evaluate the influence of time from diagnosis (Dx) to resection (Rx) on survival outcomes among patients with resectable, metachronous CRLM and to compare practice patterns across hospitals.

STUDY DESIGN

Medical records of patients with ≤4 metachronous CRLM treated with surgery were reviewed and analyzed retrospectively. Time from Dx to Rx was analyzed as a continuous variable and also dichotomized into 2 groups (group 1: Dx to Rx <3 months and group 2: Dx to Rx ≥3 months) for additional analysis. Survival time distributions after resection were estimated using the Kaplan-Meier method. Between-group univariate comparisons were based on the log-rank test and multivariable analysis was done using Cox proportional hazards model.

RESULTS

From 2000 to 2010, six hundred and twenty-six patients were identified. Type of initial referral (p < 0.0001) and use of neoadjuvant (p = 0.04) and/or adjuvant (p < 0.0001) chemotherapy were significantly different among hospitals. Patients treated with neoadjuvant chemotherapy (n = 108) and those with unresectable disease at laparotomy (n = 5) were excluded from final evaluation. Median overall survival and recurrence-free survival were 74 months (range 63.8 to 84.2 months) and 29 months (range 23.9 to 34.1 months), respectively. For the entire cohort, longer time from Dx to Rx was independently associated with shorter overall survival (hazard ratio = 1.12; 95% CI, 1.06-1.18; p < 0.0001), but not recurrence-free survival. Median overall survival for group 1 was 76 months (range 62.0 to 89.2 months) vs 58 months (range 34.3 to 81.7 months) in group 2 (p = 0.10). Among patients with available data pertaining to adjuvant chemotherapy (N = 457; 318 treated and 139 untreated), overall survival (87 months [range 71.2 to 102.8 months] vs 48 months [range 25.3 to 70.7 months]; p <0.0001), and recurrence-free survival (33 months [range 25.3 to 40.7 months] vs 22 months [range 14.5 to 29.5 months]; p = 0.05) were improved significantly.

CONCLUSIONS

In select patients undergoing initial resection for CRLM, longer time from Dx to Rx is independently associated with worse overall survival. In addition, despite uniform disease characteristics, practice patterns related to definitely resectable CRLM vary significantly across hospitals.

Time to Endoscopy in Patients with Colorectal Cancer: Analysis of Wait-Times

Objective. The Canadian Association of Gastroenterology Wait Time Consensus Group recommends that patients with symptoms associated with colorectal cancer (CRC) should have an endoscopic examination within 2 months. However, in a recent survey of Canadian gastroenterologists, wait-times for endoscopy were considerably longer than the current guidelines recommend. The purpose of this study was to evaluate wait-times for colonoscopy in patients who were subsequently found to have CRC through the Division of Gastroenterology at St. Paul's Hospital (SPH). Methods. This study was a retrospective chart review of outpatients seen for consultation and endoscopy ultimately diagnosed with CRC. Subjects were identified through the SPH pathology database for the inclusion period 2010 through 2013. Data collected included wait-times, subject characteristics, cancer characteristics, and outcomes. Results. 246 subjects met inclusion criteria for this study. The mean wait-time from primary care referral to first office visit was 63 days; the mean wait-time to first endoscopy was 94 days. Patients with symptoms waited a mean of 86 days to first endoscopy, considerably longer than the national recommended guideline of 60 days. There was no apparent effect of length of wait-time on node positivity or presence of distant metastases at the time of diagnosis. Conclusion. Wait-times for outpatient consultation and endoscopic evaluation at the St. Paul's Hospital Division of Gastroenterology exceed current guidelines.

Análise dos determinantes que influenciam o tempo para o início do tratamento de mulheres com câncer de mama no Brasil

Este estudo teve como objetivo analisar o intervalo de tempo entre o diagnóstico e o início do tratamento do câncer de mama em mulheres e seus determinantes. Foi realizado um estudo de coorte retrospectiva com 137.593 mulheres diagnosticadas em 239 unidades hospitalares do Brasil entre 2000 a 2011. Em 63,1% dos casos, o intervalo entre o diagnóstico e o tratamento foi de até 60 dias. No país, as mulheres mais suscetíveis ao atraso foram não brancas (OR = 1,18; IC95%: 1,13-1,23), sem companheiro (OR = 1,05; IC95%: 1,01-1,09), com menos de oito anos de estudo (OR = 1,13; IC95%: 1,08-1,18), com doença em estadiamento inicial (OR = 1,27; IC95%: 1,22-1,32), tratadas de 2006 a 2011 (OR = 1,54; IC95%: 1,47-1,60) e provenientes do sistema público de saúde (OR = 1,19; IC95%: 1,13-1,25). Na análise estratificada foi observada a variabilidade dos fatores entre as regiões do Brasil. A identificação de fatores associados à demora no início do tratamento poderá possibilitar a elaboração de propostas de intervenções destinadas a grupos populacionais específicos.

Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies

BACKGROUND

One of the most important factors in breast cancer (BC) mortality is treatment delay. The primary goal of this survey was to identify factors affecting the total delay time (TDT) in Turkish BC patients.

METHODS

A total of 1031 patients with BC were surveyed using a uniform questionnaire. The time between discovering the first symptom and signing up for the first medical visit (patient delay time; PDT) and the time between the first medical visit and the start of therapy (system delay time; SDT) were modelled separately with multilevel regression.

RESULTS

The mean PDT, SDT and TDT were 4.8, 10.5 and 13.8 weeks, respectively. In all, 42% of the patients had a TDT >12 weeks. Longer PDT was significantly correlated with disregarding symptoms and having age of between 30 and 39 years. Shorter PDT was characteristic of patients who: had stronger self-examination habits, received more support from family and friends and had at least secondary education. Predictors of longer SDT included disregard of symptoms, distrust in success of therapy and medical system and having PDT in excess of 4 weeks. Shorter SDT was linked to the age of >60 years. Patients who were diagnosed during a periodic check-up or opportunistic mammography displayed shorter SDT compared with those who had symptomatic BC and their first medical examination was by a surgeon.

CONCLUSION

TDT in Turkey is long and remains a major problem. Delays can be reduced by increasing BC awareness, implementing organized population-based screening programmes and founding cancer centres.

Help-seeking experiences of men diagnosed with colorectal cancer: a qualitative study

Advanced-stage diagnosis of colorectal cancer (CRC) leads to poor prognosis and reduced survival rates. The current study seeks to explore the reasons for diagnostic delays in a sample of Australian men with CRC. Semi-structured interviews were conducted in a purposive sample of 20 male CRC patients. Data collection ceased when no new data emerged. Interviews were audiotaped, transcribed and thematically analysed using Andersen's Model of Total Patient Delay as the theoretical framework. Most participants (18/20) had experienced lower bowel symptoms prior to diagnosis. Patient-related delays were more common than delays attributable to the health-care system. Data regarding patient delays fit within the first four stages of Andersen's model. The barriers to seeking timely medical advice were mainly attributed to misinterpretation of symptoms, fear of cancer diagnosis, reticence to discuss the symptoms or consulting a general practitioner. Treatment delays were a minor cause for delayed diagnosis. Delay in referral and scheduling for colonoscopy were among the system-delay factors. In many instances, delays resulted from men's failure to attribute their symptoms to cancer and, subsequently, delay in diagnosis.

The association of time between diagnosis and major resection with poorer colorectal cancer survival: a retrospective cohort study

Background

Colorectal cancer survival in the UK is lower than in other developed countries, but the association of time interval between diagnosis and treatment on excess mortality remains unclear.

Methods

Using data from cancer registries in England, we identified 46,511 patients with localised colorectal cancer between 1996–2009, who were 15 years and older, and who underwent a major surgical resection within 62 days of diagnosis. We used relative survival and excess risk modeling to investigate the association of time between diagnosis and major resection (exposure) with survival (outcome).

Results

Compared to patients who had major resection within 25–38 days of diagnosis, patients with a shorter time interval between diagnosis and resection and those waiting longer for resection had higher excess mortality (Excess Hazards Ratio, EHR <25 vs 25–38 days: 1.50; 95% Confidence Interval, CI: 1.37 to 1.66; EHR 39–62 vs 25–38 days : 1.16; 95% CI: 1.04 to 1.29). Excess mortality was associated with age (EHR 75+ vs. 15–44 year olds: 2.62; 95% CI: 2.00 to 3.42) and deprivation (EHR most vs. least deprived: 1.27; 95% CI: 1.12 to 1.45), but time between diagnosis and resection did not explain these differences.

Conclusion

Within 62 days of diagnosis, a U-shaped association of time between diagnosis and major resection with excess mortality for localised colorectal cancer was evident. This indicates a complicated treatment pathway, particularly for patients who had resection earlier than 25 days, and requires further investigation.

The dilemma of distance: patients with kidney cancer from regional Australia present at a more advanced stage

OBJECTIVE

To determine whether patients from regional areas undergoing surgery for kidney cancer present with more advanced disease as a result of geographic isolation.

PATIENTS AND METHODS

Retrospective analysis of 221 patients undergoing surgery for renal cell carcinoma (RCC) from January 2004 to June 2012, from both a metropolitan centre and a large inner regional hospital. Data was collected on age, gender, presentation (incidental or symptomatic), clinical stage and pathological features. The Australian Standard Geographical Classification-Remoteness Area (ASGC-RA) is a system developed to allow quantitative comparisons between metropolitan and rural Australia. A score was assigned to each patient based on their location of residence at the time of surgery: metropolitan, RA1; inner regional, RA2; outer regional, RA3. Statistical significance was specified as P < 0.05 on Pearson's chi-square tests.

RESULTS

Patients in each ASGC-RA group did not differ significantly in age, sex or mode of presentation. Pathological T stage on presentation increased with increasing ASGC-RA and thus distance from tertiary centres (P = 0.004). The proportion of patients with ≥T3 disease rose from 30% of RA1 to 73% of RA3 patients (P = 0.016) treated at our tertiary centre. Similarly, our regional centre had a larger proportion of patients presenting with ≥T3 disease from RA3 (31% vs 5%, P = 0.003). When the 221 patients with RCC were analysed as a group, clinical T stage was significantly associated with ASGC-RA (P < 0.001), symptomatic presentation (P < 0.001), N stage (P < 0.001), M stage (P < 0.001) and Fuhrman grade (P < 0.001).

CONCLUSIONS

Our data quantifies the detrimental effect of physical distance on the health outcomes of regional Australians with kidney cancer. Australia's unique geography and rural culture may preclude any attempts to centralise cancer care to specialised metropolitan units, as has occurred in other countries.

Time from first presentation in primary care to treatment of symptomatic colorectal cancer: effect on disease stage and survival

Background:

British 5-year survival from colorectal cancer (CRC) is below the European average, but the reasons are unclear. This study explored if longer provider delays (time from presentation to treatment) were associated with more advanced stage disease at diagnosis and poorer survival.

Methods:

Data on 958 people with CRC were linked with the Scottish Cancer Registry, the Scottish Death Registry and the acute hospital discharge (SMR01) dataset. Time from first presentation in primary care to first treatment, disease stage at diagnosis and survival time from date of first presentation in primary care were determined. Logistic regression and Cox survival analyses, both with a restricted cubic spline, were used to model stage and survival, respectively, following sequential adjustment of patient and tumour factors.

Results:

On univariate analysis, those with <4 weeks from first presentation in primary care to treatment had more advanced disease at diagnosis and the poorest prognosis. Treatment delays between 4 and 34 weeks were associated with earlier stage (with the lowest odds ratio occurring at 20 weeks) and better survival (with the lowest hazard ratio occurring at 16 weeks). Provider delays beyond 34 weeks were associated with more advanced disease at diagnosis, but not increased mortality. Following adjustment for patient, tumour factors, emergency admissions and symptoms and signs, no significant relationship between provider delay and stage at diagnosis or survival from CRC was found.

Conclusions:

Although allowing for a nonlinear relationship and important confounders, moderately long provider delays did not impact adversely on cancer outcomes. Delays are undesirable because they cause anxiety; this may be fuelled by government targets and health campaigns stressing the importance of very prompt cancer diagnosis. Our findings should reassure patients. They suggest that a health service's primary emphasis should be on quality and outcomes rather than on time to treatment.

A patient-centred approach toward surgical wait times for colon cancer: a population-based analysis

BACKGROUND

Administrative wait times reflect the time from the decision to treat until surgery; however, this does not reflect the total time a patient actually waits for treatment. Several factors may prolong the wait for colon cancer surgery. We sought to analyze the time from the date of surgical consultation to the date of surgery and any events within this time frame that may extend wait times.

METHODS

We retrospectively reviewed the cases of all adult patients in Ontario aged 18-80 years with diagnosed colon cancer who did not receive neoadjuvant therapy and underwent resection electively between Jan. 1, 2002, and Dec. 31, 2009. Wait times were measured from the date of surgical consultation to the date of surgery. We chose a wait time of 28 days, reflecting local administrative targets, as a comparative benchmark. We performed univariate and multivariate analyses to identify variables contributing to a waits longer than 28 days. Variables were analyzed in continuous linear and logistic regression models.

RESULTS

We included 10 223 patients in our study. The median wait time from initial surgical consultation to resection was 31 (range 0-182) days. Age older than 65 years had a negative impact on wait time. Preoperative services, including computed tomography, cardiac consultation, echocardiography, multigated acquisition scan, magnetic resonance imaging, colonoscopy and cardiac catheterization also significantly increased wait times. Wait times were longer in rural hospitals.

CONCLUSION

Preoperative services significantly increased wait times between initial surgical consultation and surgery.